template for a systematic literature review protocol

The Graduate Health & Life Sciences Research Library at Georgetown University Medical Center

Systematic reviews.

• Should I do a systematic review?
• Writing the Protocol
• Building a Systematic Search
• Where to Search
• Managing Project Data
• How can a DML librarian help?

How do I write a protocol?

The protocol serves as a roadmap for your review and specifies the objectives, methods, and outcomes of primary interest of the systematic review. Having a protocol promotes transparency and can be helpful for project management. Some journals require you to submit your protocol along with your manuscript. 

A good way to familiarize yourself with research protocols is to take a look at those registered on PROSPERO. PROSPERO's registration form includes 22 mandatory fields and 18 optional fields which will help you to explain every aspect of your research plan. 

• PROSPERO - International prospective register of systematic reviews

A protocol ideally includes the following:

• Databases to be searched and additional sources (particularly for grey literature)
• Keywords to be used in the search strategy
• Limits applied to the search
• Screening process
• Data to be extracted
• Summary of data to be reported

Once you have written your protocol, it is advisable to register it. Registering your protocol is a good way to announce that you are working on a review, so that others do not start working on it.

The University of Warwick's protocol template is available below and is a great tool for planning your protocol. 

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• Last Updated: Apr 2, 2024 9:22 AM
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• HSL Academic Process
• Systematic Reviews
• Step 2: Develop a Protocol

Systematic Reviews: Step 2: Develop a Protocol

Created by health science librarians.

• Step 1: Complete Pre-Review Tasks

Do I need to write a protocol?

Writing a protocol, make your protocol visible.

• Protocol FAQs
• Step 3: Conduct Literature Searches
• Step 4: Manage Citations
• Step 5: Screen Citations
• Step 6: Assess Quality of Included Studies
• Step 7: Extract Data from Included Studies
• Step 8: Write the Review

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About Step 2: Develop a Protocol

In Step 2, you will write your systematic review protocol. This is a detailed work plan for your systematic review. You will:

• Define the criteria you will use to screen literature.
• Decide where and how you will search for literature.
• Choose quality assessment tools to evaluate the literature.
• Decide how you will extract data from the articles you include.
• Upload your protocol to a website or registry to make it available to the public.

This page has checklists and templates to help you write your protocol. Librarians can help you refine your protocol based on systematic review best-practices.

Click an item below to see how it applies to Step 2: Develop a Protocol.

Reporting your review with PRISMA

For PRISMA, there are specific items you will want to report in your protocol.  For this step, review the PRISMA-P standards and the explanation document.

• PRISMA-P for Protocols
• PRISMA-P Explanation & Elaboration document
• PRISMA-P Checklist

Managing your review with Covidence

Covidence is a tool that can be used for screening, quality assessment, and data extraction. Decisions made in this stage will inform the logistics and completion of future review steps. Specify the use of Covidence in the protocol, if applicable, and note team member roles for these tasks.

How a librarian can help with Step 2

When writing your protocol, a librarian can help you :

• Develop and refine your research plan according to systematic review best practices 
• Advise on your literature searching methods documentation 
• Determine if/where to publish or share your completed protocol

What is a protocol? 

A protocol is a detailed work plan that describes how and why you are doing a systematic review. It includes your rationale and objectives, how you will search for literature, and how you will screen and synthesize what you find. It is best practice to develop a protocol and make it publicly available before starting a systematic review. 

Why should you write a protocol?

Your protocol will help your team navigate the systematic review process. It will also show readers how your completed systematic review might be different from your plan. This can help them understand whether there is any bias in your review results and conclusions. 

Uploading your protocol

You can upload a review protocol to a website or registry and make it accessible so researchers can know what reviews are planned or in process. While not an inclusive list, several options of places to upload or deposit your protocol can be found in our Protocol FAQ .  

Writing a Review Protocol: Good Practice and Common Errors

                            HSL Protocol Template                     

What to Include

Many  elements of a systematic review will need to be detailed in advance in the protocol. An example of items included in the protocol are:

• Team members
• Rationale and objectives of the review
• Eligibility criteria (also referred to as inclusion and exclusion criteria)
• Databases and key terms of the literature search (ideally, a full search strategy for at least one database)
• Process and tools for study selection (screening) , quality assessment , and data extraction
• Data items that will be extracted
• Methods of data synthesis

Use PRISMA to write your protocol

PRISMA is a set of standards about what to include in your systematic review. PRISMA 2015 has a special extension specifically for the best protocol reporting methods. The documents linked below (PRISMA-P Statement, E&E, and PRISMA-P Checklist) provide detailed instructions about how to write a good protocol.

• PRISMA-P 2015 Statement PRISMA reporting guideline for systematic review protocols.
• PRISMA-P 2015 E&E PRISMA-P Elaboration & Explanation document of the 2015 Statement (includes examples).
• PRISMA-P 2015 Checklist Choose between PDF and Word versions of the PRISMA-P 2015 Checklist
• UNC HSL Systematic Review Protocol Template Word document protocol template for systematic review protocols adapted from the PRISMA-P checklist
• Review Protocol Template by Sarah Vistintini A downloadable Word document that can be used to draft a systematic review protocol
• Evidence Synthesis Protocol Template A downloadable Word document that can be used to create a systematic review protocol
• PROSPERO Protocol Registration Form A PDF of the PROSPERO registration form
• Open Science Framework (OSF) Systematic Review Protocol Open Science Framework's (OSF) protocol template for preregistering systematic reviews, scoping reviews, and meta-analyses

You can upload your protocol to a website or registry and make it available to others. There are several places to upload or deposit your protocol listed below.  Alternatively, some journals publish systematic review protocols. If you plan to publish your protocol in a journal, make sure to check the protocol requirements on the journal website before submitting.

Compare protocol registries to see which tool might meet your needs.

• PROSPERO International prospective register of systematic reviews. Free.
• Open Science Framework (OSF) Open repository for scientific research. Free.
• Carolina Digital Repository Long-term storage and access for scholarly works, datasets, research materials and records produced by the UNC-CH community (free). Choose "Other Deposits" and then select "Poster, Presentation, Protocol, or Paper".
• Research Registry Register all types of research studies, from ‘first in man’ case reports to observational/interventional studies to systematic reviews and meta-analyses. Not free.
• INPLASY- The International Platform of Registered Systematic Review and Meta-analysis Protocols An international database created to help researchers around the world to register their systematic review protocols. Not free.
• Protocols.io A secure platform for developing and sharing reproducible methods. Create a protocol, collaborate with your team, then run as a checklist. Free.
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• Next: Step 3: Conduct Literature Searches >>
• Last Updated: Mar 28, 2024 9:43 AM
• URL: https://guides.lib.unc.edu/systematic-reviews

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Systematic Review Service

• Review Types
• How Long Do Reviews Take
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• Policies for Partnering with an MSK Librarian
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• Step 1: Form Your Team
• Step 2: Define Your Research Question
• Step 3: Write and Register Your Protocol
• Step 4: Search for Evidence
• Step 5: Screen Your Results
• Step 6: Assess the Quality
• Step 7: Collect the Data
• Step 8: Write and Publish the Review
• Additional Resources

You Need a Systematic Review Protocol

When completed early in your review process, the protocol:

• Streamlines the process for all team members.
• Improves the quality of the resulting review.
• Saves time, as you have your plans outlined before you start.
• Increases your chances of publication, as some journals require pre-registered protocols.

The Protocol Process

• Write Your Protocol
• Register Your Protocol
• Publish Your Protocol

The  PRISMA for Systematic Review Protocols (PRISMA-P) extension  lays out everything your team needs to include in a protocol. Protocol registries follow similar, if not identical, requirements.

You have several choices as to where to register a review protocol:

• Download a  PDF of the PROSPERO Registration Form .
• Download the registration form as a  Word document . More detailed instructions are in the PDF and on the PROSPERO website.
• You must  register your protocol in PROSPERO  before beginning the data extraction phase of your review.  
• If you are performing a scoping review , your protocol is not eligible for registration on PROSPERO. Open Science Framework (OSF) Registries  is a go-to alternative.  Find out more here.   
• Research Registry's Registry of Systematic Reviews/Meta-Analyses 
• The International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY)
• Protocols.io

It is an option, but not a requirement, to publish your review protocol. Here is a selection of journals that accept them. Note that all of these journals charge article processing fees .

• BMJ Open  
• JBI Evidence Synthesis  
• JMIR Research Protocols  
• Medicine (Baltimore)  
• PLOS One   
• Systematic Reviews  

How the MSK Library Can Help

Drafts of protocols are enormously helpful to MSK librarians as they build searches that accurately reflect your topic. 

Moreover, PRISMA-P , the PRISMA extension for protocols, requires a list of information sources to be searched in your review, along with a draft of a search strategy. Your MSK librarian will work with your team to determine the sources to search and build the search, and can send this information to your team once it is ready.

Your MSK librarian can also work with you to determine the review requirements of your target journal(s), which may impact the plans for your review as reflected in your protocol.

• << Previous: Step 2: Define Your Research Question
• Next: Step 4: Search for Evidence >>
• Last Updated: Apr 3, 2024 2:00 PM
• URL: https://libguides.mskcc.org/systematic-review-service

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Article Contents

Introduction, contents of a systematic review/meta-analysis protocol, conflict of interest statement.

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How to write a systematic review or meta-analysis protocol

• Article contents
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• Supplementary Data

Julien Al Shakarchi, How to write a systematic review or meta-analysis protocol, Journal of Surgical Protocols and Research Methodologies , Volume 2022, Issue 3, July 2022, snac015, https://doi.org/10.1093/jsprm/snac015

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A protocol is an important document that specifies the research plan for a systematic review/meta analysis. In this paper, we have explained a simple and clear approach to writing a research study protocol for a systematic review or meta-analysis.

A study protocol is an essential part of any research project. It sets out in detail the research methodology to be used for the systematic review or meta-analysis. It assists the research team to stay focused on the question to be answered by the study. Prospero, from the Centre for Reviews and Dissemination at the University of York, is an international prospective register of systematic reviews and authors should consider registering their research to reduce the potential for duplication of work. In this paper, we will explain how to write a research protocol by describing what needs to be included.

Introduction

This section sets out the need for the planned research and the context of the current evidence. It should be supported by an extensive background to the topic with appropriate references to the literature. This should be followed by a brief description of the condition and the target population. A clear explanation for the rationale and objective of the project is also expected to justify the need of the study.

Methods and analysis

A detailed search strategy is necessary to be described in the protocol. It should set out which databases are to be included as well as the specific keywords be searched and publication timeframe. The inclusion/exclusion criteria should be described for the type of studies, participants and interventions. The population, intervention, comparator and outcome (PICO) framework is a useful tool to consider for this section.

The methodology of the data extraction should be detailed in this section and should include how many reviewers will be involved and how any disagreement will be resolved. The methodology to be used for quality and bias assessment of included studies should also be described in this section. Data analysis including statistical methodology needs to be established clearly in this section of the protocol. Finally details of any planned subgroup analyses should also be included.

Ethics and dissemination

Any competing interests of the researchers should also be stated in this section. The authorship of any publication should have a clear and fair criterion which should be described in this section of the protocol. By doing so, it will resolve any issues arising at the publication stage.

Funding statement

It is important to explain who are the sponsors and funders of the study. It should clearly clarify the involvement and potential influence of any party. The protocol should explicitly outline the roles and responsibilities of any funder(s) in study design, data analysis and interpretation, manuscript writing and dissemination of results.

A protocol is an important document that specifies the research plan for a systematic review or meta-analysis. It should be written in detail and researchers should aim to publish their study protocols. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement provides a useful checklist on what should be included in a systematic review [ 1 ]. In this paper, we have explained a simple and clear approach to writing a research study protocol for a systematic review or meta-analysis.

None declared.

Page   MJ , McKenzie   JE , Bossuyt   PM , Boutron   I , Hoffmann   TC , Mulrow   CD , et al.    The PRISMA 2020 statement: an updated guideline for reporting systematic reviews . BMJ   2021 ; 372 : n71 .

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Systematic Reviews: Create a Protocol

• Getting Started
• Develop a Research Question
• Create a Protocol
• Search for Literature
• Conduct Screening
• Appraise & Synthesize
• Report Results
• Types of Reviews Chart Page
• Data Management Page

Step 2: Create a Protocol

A systematic review protocol states your rationale, hypothesis, and planned methodology. Members of the team then use the protocol as a guide for conducting the research. It is recommended that you register your protocol before conducting your review. Registering your protocol will improve transparency as well as alerting other researchers of your intentions so efforts are not duplicated.

Start Writing Your Protocol with this Template

Why write a protocol.

• What's the Difference Between Registering & Publishing

Where to Register a Protocol

Standards & guidelines.

UK Libraries has developed a protocol development tool that is freely available to UK faculty, staff, and students. You will find a template with detailed guidance and examples. You will also find links back to various sections of this guide. Please do not use DMPTool to register your protocol, you will need to download the PDF and register it. You can read more about registering further down on this page.

• Starting a Review: A Protocol This template is intended to help UK students, faculty, and researchers begin a systematic review, scoping review, or other evidence synthesis. We have adapted the PRISMA Protocol Extension into this active form. Guidance is provided throughout the template.
• Developing a Protocol Using DMPTool Use this PDF to develop a protocol .

A systematic review protocol states your rationale, hypothesis, and planned methodology.  Members of the team then use the protocol as a guide for conducting the research.  It is recommended that you register your protocol before conducting your review.  Registering your protocol will improve transparency as well as alerting other researchers of your intentions so efforts are not duplicated.

Systematic Review

Alexander Flannery, Chad Venn. Healthcare Exposures Preceding Hospitalization with Sepsis: A Systematic Review. PROSPERO 2020 CRD42020216759 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020216759

Scoping Review

Osf registration and publication.

Robinson, L. E., Skaggs, P., Scutchfield, F. D., & Bell, S. (2021, December 16). A Scoping Review Examining Providers’ Stigmas and the Effects on Patients with Opioid Use Disorder: A Protocol. https://doi.org/10.17605/OSF.IO/UMJAF

What's the Difference between Registering & Publishing

A systematic review protocol can either be registered or published.  There are only a few journals that publish systematic review protocols.  Registering your protocol in an publicly accessible database is encouraged so that other authors will not complete a review on your topic.  It is a best practice to search for publicly registered reviews on your topic before starting the review process.  Registering your protocol helps to avoid unintended duplication of reviews and increases transparency.

BMJ Open Publication

Lawrence, K. A., Pachner, T. M., Long, M. M., Henderson, S., Schuman, D. L., & Plassman, B. L. (2020). Risk and protective factors of dementia among adults with post-traumatic stress disorder: a systematic review protocol.  BMJ Open, 10 (6), e035517. https://doi.org/10.1136/bmjopen-2019-035517

Skaggs, Peyton; F. Douglas Scutchfield; Robinson, Lauren E.; Bell, Sarah Beth.  A Scoping Review Examining Providers’ Stigmas and the Effects on Patients with Opioid Use Disorder: A Protocol.  https://doi.org/10.17605/OSF.IO/UMJA

• Campbell Collaboration "The Campbell Collaboration promotes positive social and economic change through the production and use of systematic reviews and other evidence synthesis for evidence-based policy and practice." Disciplines: Business and Management, Crime and Justice, Disability, Education, International Development, Knowledge Translation and Implementation, Methods, Nutrition, and Social Welfare
• Cochrane "Our mission is to promote evidence-informed health decision-making by producing high-quality, relevant, accessible systematic reviews and other synthesized research evidence. Our work is internationally recognized as the benchmark for high-quality information about the effectiveness of health care." Disciplines: Healthcare
• PROSPERO An international database of prospectively registered systematic reviews in health and social care. Key features from the review protocol are recorded and maintained as a permanent record. (Does not accept scoping reviews.) Disciplines: Health and Social Care, Welfare, Public Health, Education, Crime, Justice, and International Development
• Open Science Framework An open source web application that connects and supports the research workflow. Researchers use the OSF to collaborate, document, archive, share, and register research projects, materials, and data. OSF can be used to pre-register a systematic or scoping review protocol and to share documents such as a Zotero library, search strategies, and data extraction forms. Disciplines: Multidisciplinary

Where to Publish a Protocol

• BMJ Open BMJ Open "will consider publishing without peer review protocols that have formal ethical approval and funding from a recognised, open access advocating research-funding body". Otherwise, protocols are peer reviewed.
• Systematic Reviews, a BioMed Central journal This open access title publishes protocols of systematic reviews broadly related to health sciences.
• Cochrane Handbook for Systematic Reviews Chapter 2: Guide to the contents of a Cochrane protocol and review
• Finding What Works in Health Care: Standards for Systematic Reviews Recommended standards for developing the systematic review protocol.
• Protocol Guidance from PRISMA Resources from the team that developed PRISMA
• EQUATOR Network The EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network is an international initiative that seeks to improve the reliability and value of published health research literature by promoting transparent and accurate reporting and wider use of robust reporting guidelines.
• MECIR (Methodological Expectations for Cochrane Intervention Reviews) Manual Guidelines on reporting protocols for Cochrane Intervention reviews

Searching the Grey Literature: a Handbook for Searching Reports, Working Papers, and Other Unpublished Research

Umbrella Reviews: Evidence Synthesis with Overviews of Reviews and Meta-Epidemiologic Studies

Cochrane Handbook for Systematic Reviews of Interventions

Comprehensive Systematic Review for Advanced Practice Nursing, Second Edition

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• Next: Search for Literature >>
• Last Updated: Jan 12, 2024 3:52 PM
• URL: https://libguides.uky.edu/systematicreview

Doing a systematic review

Creating a protocol, pico framework for structuring your research, alternative frameworks.

• Step 2: choosing where to search
• Step 3: developing a search strategy
• Step 4: running & recording your search
• Step 5: managing your search results
• Step 6: screening & evaluating
• Step 7: synthesis and writing it up (including PRISMA flow diagrams)

Finding reviews in progress and examples

Use the PROSPERO database to find examples of protocols and details of reviews in progress. If you are planning to publish your review check PROSPERO to make sure someone isn't already investigating that area. It is also a good idea to register your own review here once you've established its uniqueness.

• PROSPERO This international database covers prospectively registered systematic reviews in health and social care, welfare, public health, education, crime, justice, and international development, where there is a health related outcome.

Software for managing your review

• RevMan Review Manager (RevMan) is Cochrane's software for preparing and maintaining Cochrane reviews, although it can be used for non-Cochrane reviews too. If you are doing a professional systematic review leading to publication you may wish to consider using it to help manage the process. RevMan facilitates preparation of protocols and full reviews, including text, characteristics of studies, comparison tables, and study data. It can perform meta-analysis of the data entered, and present results graphically.

• research question and aims
• criteria for inclusion and exclusion
• search strategy
• selecting studies for inclusion
• quality assessment
• data extraction & analysis
• synthesis of results
• dissemination
• time frame.

You may wish to do some scoping searches of relevant databases to find out how much has been written, and what limits you should apply.

• Systematic review protocol template Use this Word document to help you plan your review and develop your protocol
• Systematic review protocol example An example of using the protocol template to plan a systematic review.
• The review protocol Produced by the Centre for Reviews and Dissemination this detailed guidance covers elements to consider when creating a review protocol.
• Watch our video introductions to doing a systematic review Watch video 2 in our series of videos on doing a systematic review for brief guidance on creating your protocol.

There are several different frameworks you can use to help structure your research and ensure you have clear parameters for your search. The most commonly used one used for health-related reviews is the PICO framework:

• Population This could be the general population, or a specific group defined by: age (e.g. infants, children, adolescents, elderly); socioeconomic status (e.g. low-income, homeless); risk status; location (rural or urban)
• Intervention Refers to the therapy, test, strategy to be investigated (e.g. drug, behavioural change, environmental factors, counselling)
• Comparator A measure you will use to compare results against (e.g. no treatment, alternative treatment/exposure, standard/routine interventions)
• Outcome What outcome is significant to your population or issue? This may be different from the outcome measures used in the studies.

PICO example

This example is extracted from: PROSPERO 2018 CRD42018100888 .

Further information

• Developing an efficient search strategy using PICO A tool created by Health Evidence which can be used to: develop a clear, answerable question that can be used to generate a search strategy; identify key search terms to facilitate a more efficient search; and to document search strategies/terms for future search updates, either in the same or similar topics.

Another framework may be more suitable depending on your review topic. Here are some other options:

• PECO – Population | Environment | Comparison | Outcome Very similar to PICO but looking at the effect of exposure to something e.g. smoky atmosphere
• SPICE - Setting | Population | Intervention | Comparison | Evaluation Another variant of PICO but this time including the setting (where? in what context?)
• CIMO - Context | Intervention | Mechanisms | Outcome A variant of PICO suitable for management and organisation studies
• ECLIPSE - Expectation | Client group | Location | Impact | Professionals | SErvice Recommended for health policy/management searches
• SPIDER – Sample | Phenomenon of Interest | Design | Evaluation | Research Type Developed to create effective search strategies of qualitative and mixed-methods research - more specific than PICO/PECO
• Developing a research question This guide from the University of Maryland includes a comprehensive list of other frameworks.
• How CLIP became ECLIPSE: a mnemonic to assist in searching for health policy/management information Article about the development of the ECLIPSE framework.
• Beyond PICO: the SPIDER tool for qualitative evidence synthesis. A comparison of the PICO and SPIDER frameworks for creating search strategies.
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• Next: Step 2: choosing where to search >>
• Last Updated: Mar 21, 2024 6:49 PM
• URL: https://libguides.reading.ac.uk/systematic-review

Systematic Reviews and Meta Analysis

• Getting Started
• Guides and Standards
• Review Protocols
• Databases and Sources
• Randomized Controlled Trials
• Controlled Clinical Trials
• Observational Designs
• Tests of Diagnostic Accuracy
• Software and Tools
• Where do I get all those articles?
• Collaborations
• EPI 233/528
• Countway Mediated Search
• Risk of Bias (RoB)

Living Systematic Review

Carole Mitnick, Molly Franke, Celia Fung, Andrew Lindeborg. Clinical Outcomes of Individuals with COVID-19 and Tuberculosis Disease: a Living Systematic Review . PROSPERO 2020 CRD42020187349 

Systematic Review and Meta-Analysis

Brindle ME, Roberts DJ, Daodu O, Haynes AB, Cauley C, Dixon E, La Flamme C, Bain P, Berry W. Deriving literature-based benchmarks for surgical complications in high-income countries: a protocol for a systematic review and meta-analysis. BMJ Open. 2017 May 9. PMID: 28487456

We require a completed protocol before we will carry out final searches on any knowledge synthesis project.

We encourage you to use this template, which is based on the PRISMA-P checklist (Moher D, et al. Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1. PMID: 25554246 .)

• Countway Protocol Template

Why a Protocol

From the Cochrane Handbook :

“The protocol sets out the context in which the review is being conducted. It presents an opportunity to develop ideas that are foundational for the review.” “Preparing a systematic review is complex and involves many judgements. To minimize the potential for bias in the review process, these judgements should be made as far as possible in ways that do not depend on the findings of the studies included in the review.” “Publication of a protocol for a review that is written without knowledge of the available studies reduces the impact of review authors’ biases, promotes transparency of methods and processes, reduces the potential for duplication, allows peer review of the planned methods before they have been completed, and offers an opportunity for the review team to plan resources and logistics for undertaking the review itself.”

Lasserson TJ, Thomas J, Higgins JPT. Chapter 1: Starting a review. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.4 (updated August 2023). Cochrane, 2023. Available from www.training.cochrane.org/handbook.

A protocol is your plan for carrying out your knowledge synthesis. It presents the rationale for carrying out the project and clearly states the aims of the work. The protocol describes the process for selecting research for inclusion, including the provision of explicit criteria for assessing reports for inclusion and for analyzing the included reports. Hence, it is an internal document that helps team members work together more smoothly. But it also is a hedge against bias by clearly stating the rules of the game before any work has begun. A protocol makes it more difficult to alter selection patterns based on perceived results. Beyond acting as a roadmap for your research, protocols, when registered or published in some way, allow others to see your research plan, establishing priority and reducing the risk of duplicate research.

Protocol Reporting Guidelines

• PRISMA (Preferred Reporting Items for Systematic Reviews) PRISMA-P was published in 2015 aiming to facilitate the development and reporting of systematic review protocols.
• MECIR (Methodological Expectations of Cochrane Intervention Reviews) Standards for the conduct of new Cochrane Intervention Reviews, and the planning and conduct of updates

Protocol Registries

• PROSPERO International prospective register of systematic reviews
• OSF (Open Science Framework) OSF is a free, open platform to support your research and enable collaboration.
• Cochrane If planning a Cochrane Review, you must publish your protocol with them after your proposal has been accepted.

Additional Resources

• Writing a review protocol - good practice and common errors This is a two part webinar provided by Cochrane Training intended to provide up to date guidance for review authors wishing to learn more about developing their own protocol.
• << Previous: Guides and Standards
• Next: Databases and Sources >>
• Last Updated: Feb 26, 2024 3:17 PM
• URL: https://guides.library.harvard.edu/meta-analysis

Template for a Systematic Literature Review Protocol

• Roberto Rafael Cruz-Martínez (Creator)
• University of Twente

Description

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Systematic reviews.

• What is a Systematic Review?
• Getting started
• Planning your search
• Writing a protocol
• Transferring your search
• Managing your references
• Further help and support

What is a protocol? 

Protocol guidance can be found in PRISMA P statement   (medicine and health-related disciplines) or from ROSES (environmental science related disciplines).

Take a look at the following for further information:

• PRISMA checklist
• PRISMA flow diagram
• ROSES for systematic map protocol
• ROSES for systematic review protocol
• ROSES flow diagram

Your protocol needs to include the following and its aim is to keep your SR on track and focused.

• Rationale / conceptual discussion of problem (background info)
• The review question (s) and objective (s)
• Search strategy
• Study selection criteria
• Study quality assessment
• Data extraction procedure
• Data synthesis procedure
• Project timetable

Where do I register it?

• PROSPERO  -  International Prospective Register of Systematic Reviews. Registration is free and open to anyone undertaking systematic reviews of the effects of interventions and strategies to prevent, diagnose, treat, and monitor health conditions, for which there is a health related outcome.
• The Cochrane Collaboration: Proposing and registering new reviews  - This page gives the steps on how to register your proposed Cochrane Review with a Cochrane Review Group.
• Center for Open Science  -  Register your protocol or research project, or consider uploading a preprint.

The benefits of a protocol

• Raises awareness of the review
• Promotes a systematic rather than ad hoc approach to the review
• ​Provides a public record of planned methods - reduces risk of bias
• ​Facilitates communication with others and promotes consistency between review team members
• ​​Tracks use and impact of published reviews
• ​Permanent record whether final report published or not

Article: Best Practices in Systematic Reviews: The Importance of Protocols and Registration

If you want to read further, why not check out Planning a Systematic Review: think protocols blog post by BMC on the benefits?

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• Last Updated: Feb 28, 2024 4:24 PM
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• 1. Assemble Your Team
• 2. Develop a Research Question
• 3. Write and Register a Protocol
• 4. Search the Evidence
• 5. Screen Results
• 6. Assess for Quality and Bias
• 7. Extract the Data
• 8. Write the Review
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The Whats and Whys of Protocols

Systematic reviews and scoping reviews should have a protocol which helps to plan and outline the study methodology. The protocol should include:

• the rationale for the review
• key questions broken into PICO (or other structured research question) components
• inclusion/exclusion criteria
• literature searches for published/unpublished literature
• data abstraction/data management
• assessment of methodological quality/risk of bias of individual studies (not required for scoping reviews)
• data synthesis
• grading the evidence for each key question

Why should complete a protocol?

• A protocol is your planning document and roadmap for the project. It allows you to complete a systematic review efficiently and accurately, ensures greater understanding among team members, and makes writing the manuscript far easier.
• Many journals now require submitted systematic reviews to have registered protocols.
• The PRISMA Reporting Standard lists information about the systematic review protocol as an "essential element" (PRISMA 2020 Item 24)
• The Cochrane Handbook, The Institute of Medicine Standards, and others, all list completing a protocol as one of the important steps to a successful systematic review.
• Best practices in systematic reviews: the importance of protocols & registration
• Planning a systematic review? Think protocols

Writing a Protocol

Protocol templates:

• PRISMA for systematic review protocols (PRISMA-P) Checklist and explanation of what should be included in a systematic review protocol.
• The PROSPERO systematic review protocol template
• OSF Scoping Review Protocol Template and Guidance Document "The Guidance document is intended to be used in tandem with the Scoping Review Protocol Template. The Guidance document includes tips, examples, and details about each section of the protocol. The Template includes headings and subheadings to use to structure the protocol (e.g., which order to present the information, what level of detail, etc.).”
• JBI scoping review protocol template

Resources to help authors prepare a protocol for a systematic or scoping review:

• Institute of Medicine – Standards for Systematic Reviews - Section 2.6
• The Cochrane Handbook - Section ii.1.4
• JBI Manual for Evidence Synthesis - Section 1.3 (Systematic reviews) & 11.2 (Scoping reviews)

Where to Register a Protocol

After you write the protocol, you should register it with a review registry. There are numerous review registries available, such as PROSPERO or OSF. Registration is free and open to anyone undertaking systematic reviews. Some journals also publish systematic review protocols.

• PROSPERO A registry for systematic review protocols
• How to register with PROSPERO

OSF can be used to pre-register a systematic or scoping review protocol and to share documents such as a citation management library, search strategies, and data extraction forms. Unlike other registries, evidence synthesis author teams do not submit their protocols for review by an editorial board before they are accepted and pre-registered on OSF. Instead, create your own pre-registration.

• How to create an OSF registration
• OSF Registrations Form

Scoping reviews may not be registered with PROSPERO.  Currently, they can be registered with the Open Science Framework or Figshare.

Publishing a Protocol

• BioMed Central Protocols BioMed Central will consider protocols of any type of research for publication, following the standard peer review.
• BMJ Open BMJ Open "will consider publishing without peer review protocols that have formal ethical approval and funding from a recognized, open access advocating research-funding body". Otherwise, protocols are peer reviewed.
• JBI Evidence Synthesis Like systematic reviews, scoping review protocols can be published in some journals.
• Systematic Reviews, a BioMed Central journal This open access title publishes protocols of systematic reviews broadly related to health sciences.
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Systematic reviews: Write a protocol

• Introduction
• Formulate your question
• Write a protocol
• Search the literature
• Manage references
• Select studies
• Assess the evidence
• Write your review
• Further resources

What is a protocol?

The protocol is a published plan that describes the objectives and methods you will follow for your review.

• A good protocol will ensure that your review will go smoothly.  It should be built on a sound research question, with strict inclusion/exclusion criteria, and firm ideas about data extraction and quality assessment.
• During the drafting of the protocol, you will be developing your research question and testing your search strategy in one database, including choosing the keywords to use and which studies to include or exclude.  The frameworks described in  Formulate your question , including PICO, may help you develop your research question and search strategy.
• It is important that you confirm that your review has not been done before, by checking the registers of completed or in-progress reviews.
• It is recommended that you register your own finalised protocol, so that other researchers are made aware of your review and you are able to cite it.

Looking for protocols

Before you write your protocol and to ensure the uniqueness of your review, you should search the registers of completed and ongoing studies. Below, are some suggested starting-points for your searches.

Writing a protocol

When designing your protocol, refer to the reporting guidance for your type of review, to ensure that you do not forgot to include something in the initial stages that you are expected to report at the end. For example, the PRISMA  website has a minimum set of 27 items that should be reported, including the methods and results.

PRISMA stands for Preferred Reporting Items for Systematic Reviews and Meta-Analyses.  PRISMA  is designed for reviews that evaluate randomized trials, although it can be used to report systematic reviews of other types of research, particularly evaluations of interventions.

Registering your protocol

It is recommended that you add your final protocol to a register to raise awareness among researchers. PROSPERO is just one register you might want to consider:

Inclusion/exclusion criteria

The Library of the University of Melbourne provides a helpful infographic about common inclusion or exclusion criteria .

More advice about writing a protocol

Module 2  in  Cochrane Interactive Learning  provides advice about the key components and structure of a protocol.  The Library is subscribing to  Cochrane Interactive Learning .  

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• URL: https://library.bath.ac.uk/systematic-reviews

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Cochrane Training

Chapter 1: starting a review.

Toby J Lasserson, James Thomas, Julian PT Higgins

Key Points:

• Systematic reviews address a need for health decision makers to be able to access high quality, relevant, accessible and up-to-date information.
• Systematic reviews aim to minimize bias through the use of pre-specified research questions and methods that are documented in protocols, and by basing their findings on reliable research.
• Systematic reviews should be conducted by a team that includes domain expertise and methodological expertise, who are free of potential conflicts of interest.
• People who might make – or be affected by – decisions around the use of interventions should be involved in important decisions about the review.
• Good data management, project management and quality assurance mechanisms are essential for the completion of a successful systematic review.

Cite this chapter as: Lasserson TJ, Thomas J, Higgins JPT. Chapter 1: Starting a review. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.4 (updated August 2023). Cochrane, 2023. Available from www.training.cochrane.org/handbook .

1.1 Why do a systematic review?

Systematic reviews were developed out of a need to ensure that decisions affecting people’s lives can be informed by an up-to-date and complete understanding of the relevant research evidence. With the volume of research literature growing at an ever-increasing rate, it is impossible for individual decision makers to assess this vast quantity of primary research to enable them to make the most appropriate healthcare decisions that do more good than harm. By systematically assessing this primary research, systematic reviews aim to provide an up-to-date summary of the state of research knowledge on an intervention, diagnostic test, prognostic factor or other health or healthcare topic. Systematic reviews address the main problem with ad hoc searching and selection of research, namely that of bias. Just as primary research studies use methods to avoid bias, so should summaries and syntheses of that research.

A systematic review attempts to collate all the empirical evidence that fits pre-specified eligibility criteria in order to answer a specific research question. It uses explicit, systematic methods that are selected with a view to minimizing bias, thus providing more reliable findings from which conclusions can be drawn and decisions made (Antman et al 1992, Oxman and Guyatt 1993). Systematic review methodology, pioneered and developed by Cochrane, sets out a highly structured, transparent and reproducible methodology (Chandler and Hopewell 2013). This involves: the a priori specification of a research question; clarity on the scope of the review and which studies are eligible for inclusion; making every effort to find all relevant research and to ensure that issues of bias in included studies are accounted for; and analysing the included studies in order to draw conclusions based on all the identified research in an impartial and objective way.

This Handbook is about systematic reviews on the effects of interventions, and specifically about methods used by Cochrane to undertake them. Cochrane Reviews use primary research to generate new knowledge about the effects of an intervention (or interventions) used in clinical, public health or policy settings. They aim to provide users with a balanced summary of the potential benefits and harms of interventions and give an indication of how certain they can be of the findings. They can also compare the effectiveness of different interventions with one another and so help users to choose the most appropriate intervention in particular situations. The primary purpose of Cochrane Reviews is therefore to inform people making decisions about health or health care.

Systematic reviews are important for other reasons. New research should be designed or commissioned only if it does not unnecessarily duplicate existing research (Chalmers et al 2014). Therefore, a systematic review should typically be undertaken before embarking on new primary research. Such a review will identify current and ongoing studies, as well as indicate where specific gaps in knowledge exist, or evidence is lacking; for example, where existing studies have not used outcomes that are important to users of research (Macleod et al 2014). A systematic review may also reveal limitations in the conduct of previous studies that might be addressed in the new study or studies.

Systematic reviews are important, often rewarding and, at times, exciting research projects. They offer the opportunity for authors to make authoritative statements about the extent of human knowledge in important areas and to identify priorities for further research. They sometimes cover issues high on the political agenda and receive attention from the media. Conducting research with these impacts is not without its challenges, however, and completing a high-quality systematic review is often demanding and time-consuming. In this chapter we introduce some of the key considerations for potential review authors who are about to start a systematic review.

1.2 What is the review question?

Getting the research question right is critical for the success of a systematic review. Review authors should ensure that the review addresses an important question to those who are expected to use and act upon its conclusions.

We discuss the formulation of questions in detail in Chapter 2 . For a question about the effects of an intervention, the PICO approach is usually used, which is an acronym for Population, Intervention, Comparison(s) and Outcome. Reviews may have additional questions, for example about how interventions were implemented, economic issues, equity issues or patient experience.

To ensure that the review addresses a relevant question in a way that benefits users, it is important to ensure wide input. In most cases, question formulation should therefore be informed by people with various relevant – but potentially different – perspectives (see Chapter 2, Section 2.4 ).

1.3 Who should do a systematic review?

Systematic reviews should be undertaken by a team. Indeed, Cochrane will not publish a review that is proposed to be undertaken by a single person. Working as a team not only spreads the effort, but ensures that tasks such as the selection of studies for eligibility, data extraction and rating the certainty of the evidence will be performed by at least two people independently, minimizing the likelihood of errors. First-time review authors are encouraged to work with others who are experienced in the process of systematic reviews and to attend relevant training.

Review teams must include expertise in the topic area under review. Topic expertise should not be overly narrow, to ensure that all relevant perspectives are considered. Perspectives from different disciplines can help to avoid assumptions or terminology stemming from an over-reliance on a single discipline. Review teams should also include expertise in systematic review methodology, including statistical expertise.

Arguments have been made that methodological expertise is sufficient to perform a review, and that content expertise should be avoided because of the risk of preconceptions about the effects of interventions (Gøtzsche and Ioannidis 2012). However, it is important that both topic and methodological expertise is present to ensure a good mix of skills, knowledge and objectivity, because topic expertise provides important insight into the implementation of the intervention(s), the nature of the condition being treated or prevented, the relationships between outcomes measured, and other factors that may have an impact on decision making.

A Cochrane Review should represent an independent assessment of the evidence and avoiding financial and non-financial conflicts of interest often requires careful management. It will be important to consider if there are any relevant interests that may constitute a conflict of interest. There are situations where employment, holding of patents and other financial support should prevent people joining an author team. Funding of Cochrane Reviews by commercial organizations with an interest in the outcome of the review is not permitted. To ensure that any issues are identified early in the process, authors planning Cochrane Reviews should consult the Conflict of Interest Policy . Authors should make complete declarations of interest before registration of the review, and refresh these annually thereafter until publication and just prior to publication of the protocol and the review. For authors of review updates, this must be done at the time of the decision to update the review, annually thereafter until publication, and just prior to publication. Authors should also update declarations of interest at any point when their circumstances change.

1.3.1 Involving consumers and other stakeholders

Because the priorities of decision makers and consumers may be different from those of researchers, it is important that review authors consider carefully what questions are important to these different stakeholders. Systematic reviews are more likely to be relevant to a broad range of end users if they are informed by the involvement of people with a range of experiences, in terms of both the topic and the methodology (Thomas et al 2004, Rees and Oliver 2017). Engaging consumers and other stakeholders, such as policy makers, research funders and healthcare professionals, increases relevance, promotes mutual learning, improved uptake and decreases research waste.

Mapping out all potential stakeholders specific to the review question is a helpful first step to considering who might be invited to be involved in a review. Stakeholders typically include: patients and consumers; consumer advocates; policy makers and other public officials; guideline developers; professional organizations; researchers; funders of health services and research; healthcare practitioners, and, on occasion, journalists and other media professionals. Balancing seniority, credibility within the given field, and diversity should be considered. Review authors should also take account of the needs of resource-poor countries and regions in the review process (see Chapter 16 ) and invite appropriate input on the scope of the review and the questions it will address.

It is established good practice to ensure that consumers are involved and engaged in health research, including systematic reviews. Cochrane uses the term ‘consumers’ to refer to a wide range of people, including patients or people with personal experience of a healthcare condition, carers and family members, representatives of patients and carers, service users and members of the public. In 2017, a Statement of Principles for consumer involvement in Cochrane was agreed. This seeks to change the culture of research practice to one where both consumers and other stakeholders are joint partners in research from planning, conduct, and reporting to dissemination. Systematic reviews that have had consumer involvement should be more directly applicable to decision makers than those that have not (see online Chapter II ).

1.3.2 Working with consumers and other stakeholders

Methods for working with consumers and other stakeholders include surveys, workshops, focus groups and involvement in advisory groups. Decisions about what methods to use will typically be based on resource availability, but review teams should be aware of the merits and limitations of such methods. Authors will need to decide who to involve and how to provide adequate support for their involvement. This can include financial reimbursement, the provision of training, and stating clearly expectations of involvement, possibly in the form of terms of reference.

While a small number of consumers or other stakeholders may be part of the review team and become co-authors of the subsequent review, it is sometimes important to bring in a wider range of perspectives and to recognize that not everyone has the capacity or interest in becoming an author. Advisory groups offer a convenient approach to involving consumers and other relevant stakeholders, especially for topics in which opinions differ. Important points to ensure successful involvement include the following.

• The review team should co-ordinate the input of the advisory group to inform key review decisions.
• The advisory group’s input should continue throughout the systematic review process to ensure relevance of the review to end users is maintained.
• Advisory group membership should reflect the breadth of the review question, and consideration should be given to involving vulnerable and marginalized people (Steel 2004) to ensure that conclusions on the value of the interventions are well-informed and applicable to all groups in society (see Chapter 16 ).

Templates such as terms of reference, job descriptions, or person specifications for an advisory group help to ensure clarity about the task(s) required and are available from INVOLVE . The website also gives further information on setting and organizing advisory groups. See also the Cochrane training website for further resources to support consumer involvement.

1.4 The importance of reliability

Systematic reviews aim to be an accurate representation of the current state of knowledge about a given issue. As understanding improves, the review can be updated. Nevertheless, it is important that the review itself is accurate at the time of publication. There are two main reasons for this imperative for accuracy. First, health decisions that affect people’s lives are increasingly taken based on systematic review findings. Current knowledge may be imperfect, but decisions will be better informed when taken in the light of the best of current knowledge. Second, systematic reviews form a critical component of legal and regulatory frameworks; for example, drug licensing or insurance coverage. Here, systematic reviews also need to hold up as auditable processes for legal examination. As systematic reviews need to be both correct, and be seen to be correct, detailed evidence-based methods have been developed to guide review authors as to the most appropriate procedures to follow, and what information to include in their reports to aid auditability.

1.4.1 Expectations for the conduct and reporting of Cochrane Reviews

Cochrane has developed methodological expectations for the conduct, reporting and updating of systematic reviews of interventions (MECIR) and their plain language summaries ( Plain Language Expectations for Authors of Cochrane Summaries ; PLEACS). Developed collaboratively by methodologists and Cochrane editors, they are intended to describe the desirable attributes of a Cochrane Review. The expectations are not all relevant at the same stage of review conduct, so care should be taken to identify those that are relevant at specific points during the review. Different methods should be used at different stages of the review in terms of the planning, conduct, reporting and updating of the review.

Each expectation has a title, a rationale and an elaboration. For the purposes of publication of a review with Cochrane, each has the status of either ‘mandatory’ or ‘highly desirable’. Items described as mandatory are expected to be applied, and if they are not then an appropriate justification should be provided; failure to implement such items may be used as a basis for deciding not to publish a review in the Cochrane Database of Systematic Reviews (CDSR). Items described as highly desirable should generally be implemented, but there are reasonable exceptions and justifications are not required.

All MECIR expectations for the conduct of a review are presented in the relevant chapters of this Handbook . Expectations for reporting of completed reviews (including PLEACS) are described in online Chapter III . The recommendations provided in the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement have been incorporated into the Cochrane reporting expectations, ensuring compliance with the PRISMA recommendations and summarizing attributes of reporting that should allow a full assessment of the methods and findings of the review (Moher et al 2009).

1.5 Protocol development

Preparing a systematic review is complex and involves many judgements. To minimize the potential for bias in the review process, these judgements should be made as far as possible in ways that do not depend on the findings of the studies included in the review. Review authors’ prior knowledge of the evidence may, for example, influence the definition of a systematic review question, the choice of criteria for study eligibility, or the pre-specification of intervention comparisons and outcomes to analyse. It is important that the methods to be used should be established and documented in advance (see MECIR Box 1.5.a , MECIR Box 1.5.b and MECIR Box 1.5.c ).

Publication of a protocol for a review that is written without knowledge of the available studies reduces the impact of review authors’ biases, promotes transparency of methods and processes, reduces the potential for duplication, allows peer review of the planned methods before they have been completed, and offers an opportunity for the review team to plan resources and logistics for undertaking the review itself. All chapters in the Handbook should be consulted when drafting the protocol. Since systematic reviews are by their nature retrospective, an element of knowledge of the evidence is often inevitable. This is one reason why non-content experts such as methodologists should be part of the review team (see Section 1.3 ). Two exceptions to the retrospective nature of a systematic review are a meta-analysis of a prospectively planned series of trials and some living systematic reviews, as described in Chapter 22 .

The review question should determine the methods used in the review, and not vice versa. The question may concern a relatively straightforward comparison of one treatment with another; or it may necessitate plans to compare different treatments as part of a network meta-analysis, or assess differential effects of an intervention in different populations or delivered in different ways.

The protocol sets out the context in which the review is being conducted. It presents an opportunity to develop ideas that are foundational for the review. This concerns, most explicitly, definition of the eligibility criteria such as the study participants and the choice of comparators and outcomes. The eligibility criteria may also be defined following the development of a logic model (or an articulation of the aspects of an extent logic model that the review is addressing) to explain how the intervention might work (see Chapter 2, Section 2.5.1 ).

MECIR Box 1.5.a Relevant expectations for conduct of intervention reviews

A key purpose of the protocol is to make plans to minimize bias in the eventual findings of the review. Reliable synthesis of available evidence requires a planned, systematic approach. Threats to the validity of systematic reviews can come from the studies they include or the process by which reviews are conducted. Biases within the studies can arise from the method by which participants are allocated to the intervention groups, awareness of intervention group assignment, and the collection, analysis and reporting of data. Methods for examining these issues should be specified in the protocol. Review processes can generate bias through a failure to identify an unbiased (and preferably complete) set of studies, and poor quality assurance throughout the review. The availability of research may be influenced by the nature of the results (i.e. reporting bias). To reduce the impact of this form of bias, searching may need to include unpublished sources of evidence (Dwan et al 2013) ( MECIR Box 1.5.b ).

MECIR Box 1.5.b Relevant expectations for the conduct of intervention reviews

Developing a protocol for a systematic review has benefits beyond reducing bias. Investing effort in designing a systematic review will make the process more manageable and help to inform key priorities for the review. Defining the question, referring to it throughout, and using appropriate methods to address the question focuses the analysis and reporting, ensuring the review is most likely to inform treatment decisions for funders, policy makers, healthcare professionals and consumers. Details of the planned analyses, including investigations of variability across studies, should be specified in the protocol, along with methods for interpreting the results through the systematic consideration of factors that affect confidence in estimates of intervention effect ( MECIR Box 1.5.c ).

MECIR Box 1.5.c Relevant expectations for conduct of intervention reviews

While the intention should be that a review will adhere to the published protocol, changes in a review protocol are sometimes necessary. This is also the case for a protocol for a randomized trial, which must sometimes be changed to adapt to unanticipated circumstances such as problems with participant recruitment, data collection or event rates. While every effort should be made to adhere to a predetermined protocol, this is not always possible or appropriate. It is important, however, that changes in the protocol should not be made based on how they affect the outcome of the research study, whether it is a randomized trial or a systematic review. Post hoc decisions made when the impact on the results of the research is known, such as excluding selected studies from a systematic review, or changing the statistical analysis, are highly susceptible to bias and should therefore be avoided unless there are reasonable grounds for doing this.

Enabling access to a protocol through publication (all Cochrane Protocols are published in the CDSR ) and registration on the PROSPERO register of systematic reviews reduces duplication of effort, research waste, and promotes accountability. Changes to the methods outlined in the protocol should be transparently declared.

This Handbook provides details of the systematic review methods developed or selected by Cochrane. They are intended to address the need for rigour, comprehensiveness and transparency in preparing a Cochrane systematic review. All relevant chapters – including those describing procedures to be followed in the later stages of the review – should be consulted during the preparation of the protocol. A more specific description of the structure of Cochrane Protocols is provide in online Chapter II .

1.6 Data management and quality assurance

Systematic reviews should be replicable, and retaining a record of the inclusion decisions, data collection, transformations or adjustment of data will help to establish a secure and retrievable audit trail. They can be operationally complex projects, often involving large research teams operating in different sites across the world. Good data management processes are essential to ensure that data are not inadvertently lost, facilitating the identification and correction of errors and supporting future efforts to update and maintain the review. Transparent reporting of review decisions enables readers to assess the reliability of the review for themselves.

Review management software, such as Covidence and EPPI-Reviewer , can be used to assist data management and maintain consistent and standardized records of decisions made throughout the review. These tools offer a central repository for review data that can be accessed remotely throughout the world by members of the review team. They record independent assessment of studies for inclusion, risk of bias and extraction of data, enabling checks to be made later in the process if needed. Research has shown that even experienced reviewers make mistakes and disagree with one another on risk-of-bias assessments, so it is particularly important to maintain quality assurance here, despite its cost in terms of author time. As more sophisticated information technology tools begin to be deployed in reviews (see Chapter 4, Section 4.6.6.2 and Chapter 22, Section 22.2.4 ), it is increasingly apparent that all review data – including the initial decisions about study eligibility – have value beyond the scope of the individual review. For example, review updates can be made more efficient through (semi-) automation when data from the original review are available for machine learning.

1.7 Chapter information

Authors: Toby J Lasserson, James Thomas, Julian PT Higgins

Acknowledgements: This chapter builds on earlier versions of the Handbook . We would like to thank Ruth Foxlee, Richard Morley, Soumyadeep Bhaumik, Mona Nasser, Dan Fox and Sally Crowe for their contributions to Section 1.3 .

Funding: JT is supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care North Thames at Barts Health NHS Trust. JPTH is a member of the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol. JPTH received funding from National Institute for Health Research Senior Investigator award NF-SI-0617-10145. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

1.8 References

Antman E, Lau J, Kupelnick B, Mosteller F, Chalmers T. A comparison of results of meta-analyses of randomized control trials and recommendations of clinical experts: treatment for myocardial infarction. JAMA 1992; 268 : 240–248.

Chalmers I, Bracken MB, Djulbegovic B, Garattini S, Grant J, Gulmezoglu AM, Howells DW, Ioannidis JP, Oliver S. How to increase value and reduce waste when research priorities are set. Lancet 2014; 383 : 156–165.

Chandler J, Hopewell S. Cochrane methods – twenty years experience in developing systematic review methods. Systematic Reviews 2013; 2 : 76.

Dwan K, Gamble C, Williamson PR, Kirkham JJ, Reporting Bias Group. Systematic review of the empirical evidence of study publication bias and outcome reporting bias: an updated review. PloS One 2013; 8 : e66844.

Gøtzsche PC, Ioannidis JPA. Content area experts as authors: helpful or harmful for systematic reviews and meta-analyses? BMJ 2012; 345 .

Macleod MR, Michie S, Roberts I, Dirnagl U, Chalmers I, Ioannidis JP, Al-Shahi Salman R, Chan AW, Glasziou P. Biomedical research: increasing value, reducing waste. Lancet 2014; 383 : 101–104.

Moher D, Liberati A, Tetzlaff J, Altman D, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Medicine 2009; 6 : e1000097.

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Self-reporting of psychoneurophysical (PNP) symptoms in adults with four chronic diseases: a protocol for a scoping review

• Carielle Joy Rio 1 ,
• Catherine Blumhorst 1 ,
• Catherine A. Kwiat 1 ,
• Christopher M. Nguyen 1 ,
• Alicia A. Livinski 2 &
• Leorey N. Saligan   ORCID: orcid.org/0000-0001-9481-7836 1  

Systematic Reviews volume  13 , Article number:  102 ( 2024 ) Cite this article

Metrics details

Patient self-reporting of health-specific information, including symptoms, allows healthcare providers to provide more timely, personalized, and patient-centered care to meet their needs. It is critical to acknowledge that symptom reporting draws from the individual’s unique sociocultural background influencing how one perceives health and illness. This scoping review will explore whether racial groups with 4 chronic diseases (cardiovascular diseases, respiratory diseases, cancers, and diabetes) differ in self-reporting of psychoneurophysical (PNP) symptoms. The PNP symptoms of interest include depressive symptoms, fatigue, anxiety, pain, cognitive impairment, sleep impairment, mood impairment, irritability, and shortness of breath.

Four databases will be searched by a biomedical librarian: CINAHL Plus (EBSCOhost), Embase (Elsevier), PubMed (NLM), Web of Science: Core Collection (Clarivate Analytics), and limited to publications written in the English language. Two independent reviewers will screen the records’ title, abstract, and then full text and extract the data from included articles using Covidence. A third reviewer will be used for resolving disagreements. Included articles must comprise adult patients with at least one of the specified chronic diseases who self-report at least one of the specified PNP symptoms. Studies that used clinician-administered questionnaires or obtained symptom responses from primary caregiver or patient designee will be excluded. Articles on patient-reported functionality or perceived quality of life will also be excluded from the review. Two reviewers will independently extract data (e.g., demographics, study design, racial group, chronic disease, measure/scale used for self-report) from each included article using Covidence and Microsoft Excel for data cleaning and analyses.

This scoping review may potentially identify the relevant and practical implications related to clinical decision-making and health outcomes for patients experiencing the psychoneurophysical symptoms included in this study. The authors will present how the results can be utilized in clinical practice, health policy, and research planning.

Systematic review registration

The protocol was registered on Open Science Framework (OSF) at: https://osf.io/ps7aw

Peer Review reports

The high prevalence of individuals with chronic diseases globally is creating significant health and economic concerns and pressures in countries around the world [ 1 ]. Seven of the 10 leading causes of death identified by the World Health Organization (WHO) in 2019 are non-communicable or chronic diseases including ischemic heart disease, stroke, chronic obstructive pulmonary disease, cancers, Alzheimer’s disease, diabetes mellitus, and kidney disease [ 2 ]. In 2022, the WHO reported that while life expectancy has remained constant since 2000, the number of deaths due to chronic diseases has increased from 60.8% in 2000 to 73.6% in 2019 [ 2 ]. In 2019, cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes resulted in approximately 33.2 million deaths [ 2 ]. The combined income loss of workers in the United States (US) who experience functional limitations secondary to chronic diseases is estimated at 4.95 billion US dollars [ 3 ]. The national annual spending of the US for chronic diseases, along with mental health conditions, amounts to 4.1 trillion US dollars or 90% of the yearly US healthcare expenditure [ 4 ]. More than 300 billion US dollars was spent on cardiovascular diseases alone between 2017 to 2018 [ 5 ]. These data show that chronic diseases present serious health and economic consequences.

The rising number of people living with chronic diseases prompted a shift from appointment-based consultations to patient-driven models of care where patients actively participate in monitoring and managing their own medical conditions [ 6 ]. In recent years, there has been increasing use of technologies primarily intended to facilitate symptom reporting by patients to their healthcare providers for faster clinical decision-making [ 6 , 7 ]. Patient self-reporting of health-specific information, including symptoms, allows healthcare providers to provide more timely, personalized, and patient-centered care that focuses on the patient’s physical, emotional, and practical needs. Further, patient-reporting of health information also facilitates respect and consideration of the patient’s values and preferences in planning for their care [ 8 ].

Addressing chronic diseases requires accounting for social determinants of health that influence health outcomes. Disparities in estimated chronic disease prevalence are linked to disparities involving socioeconomic, racial, and ethnic groups [ 9 ]. Poor health outcomes (i.e., controls of hypertension, hyperglycemia, hyperlipidemia, and HIV) are found to be more prevalent in minority populations [ 10 ]. The disparity in chronic disease control between races is attributed to differences in health literacy, beliefs regarding medical treatment, perceived discrimination, and access to high-performing insurance plans [ 10 ]. It is critical to acknowledge that symptom reporting draws from the individual’s unique sociocultural background influencing how one perceives health and illness. It has been established that variations in symptom experience, including interpretation and reporting, exist across cultures and contexts [ 11 ].

A study in England found that Romanians and Southeast Asians suppress symptoms of anxiety and depression due to the cultural stigma attached to these conditions, but instead report physical pain symptoms that are challenging to address [ 12 ]. These racial and cultural variations have been documented not only in mental health care assessment but also in other health conditions such as reporting menopausal symptoms, and cancer treatment experience [ 13 , 14 , 15 ]. Earlier studies found that race influences patients’ perception of symptom intensity, as well as the burden from the symptoms being experienced [ 6 ]. Low proficiency in the predominant language used in the healthcare setting, which is a significant limiting factor for immigrant populations, remains a major challenge in patient-reported approaches [ 7 ]. Understanding health behaviors such as symptom reporting ought to consider race, not only based on genetic inheritance, but also consider the disparity in the socioeconomic factors that may intersect with race [ 16 ]. Lack of access to insurance, fear of discrimination, language barrier, low literacy levels, and cultural acceptability of certain medical interventions are among the factors driving racial disparities in symptom reporting [ 7 , 10 , 12 ].

Aim and review question

Even with the strong evidence of racial disparities in patient reporting of symptoms, there is a scarcity of studies that synthesize earlier studies that explored this phenomenon. This information is critical to propose changes not only to improve our clinical practice but also to upgrade our educational milieu and revamp our research perspectives. Therefore, the aim of this review is to explore whether racial groups with four chronic diseases differ in self-reporting psychoneurophysical (PNP) symptoms. This scoping review will focus on the primary question “Do racial groups with 4 chronic diseases differ in self-reporting PNP symptoms?”.

Eligibility criteria

The following chronic diseases will be included (1) cardiovascular diseases such as ischemic heart disease or coronary artery disease, chronic heart failure, hypertension, chronic arrhythmias, peripheral vascular disease, aneurysms, and stroke; (2) respiratory diseases including chronic obstructive pulmonary diseases, interstitial pulmonary fibrosis, and asthma; (3) all cancers, and; (4) diabetes mellitus types 1 and 2. We selected these four chronic diseases as they are the leading causes of chronic disease-related deaths worldwide according to the WHO. The PNP symptoms we will include are depressive symptoms, chronic fatigue (e.g., physical, cognitive, mental), anxiety (e.g., panic disorder, general anxiety disorder, social anxiety disorder, specific phobias, separation anxiety disorder), chronic pain, cognitive impairment (e.g., mild cognitive impairment, subjective cognitive decline, brain fog, chemo brain, dementia), sleep impairment (e.g., insomnia, poor sleep quality, early waking, circadian rhythm disorders, parasomnias, sleep-related movement disorders, sleep-related breathing disorders), mood impairment (e.g. negative affect, tension, anger, emotional lability) irritability, and shortness of breath.

The review will only include articles on original research. Quantitative, qualitative, and mixed-method studies will be considered for inclusion. Editorials and commentaries will be excluded. Review articles will also not be included; however, the reference list of review articles will be scanned for original research articles that will be included for title, abstract, and full-text screening. A search for grey literature will also be conducted. This step may include full-text conference proceedings, preprints, dissertations, government documents/reports, and technical reports. Only articles published in English will be included as the review team does not have translation capabilities available.

Search strategy

The search strategy will aim to locate published primary studies and systematic reviews. An initial limited search of PubMed (US National Library of Medicine) was undertaken to identify articles on the topic to assist with keyword selection. The text words contained in the titles, abstracts, full text, and the controlled vocabulary terms used to describe the relevant articles were used to develop a full search strategy.

The databases CINAHL Plus (EBSCOhost), Embase (Elsevier), PubMed (US National Library of Medicine), and Web of Science: Core Collection (Clarivate Analytics) will be searched by a biomedical librarian. The search strategy, including all identified keywords and controlled vocabulary terms (CINAHL Subject Headings, EMTREE, MeSH), will be adapted for each included information source (see Table  1 for the final search strategy used for PubMed).

Additionally, the reference lists of articles included in the review and relevant reviews will be scanned for any additional articles, and will proceed through the screening process.

Study selection

EndNote 20 (Clarivate Analytics) will be used by the biomedical librarian to collect, organize, remove duplicates, and identify unique records for screening. Covidence (Veritas Health Innovations) will be used for the study screening steps and data extraction. Microsoft Excel will be used for data cleaning and analyses. A pilot test of the screening step will be conducted in Covidence with all reviewers using a random sample of 20 records selected by the biomedical librarian. Screening will occur in two stages: (1) title and abstracts and (2) full text. After the pilot test, the team will meet and review the process, address questions, and update the eligibility criteria as necessary.

Once the questions during the pilot test are addressed and the steps are finalized, the titles and abstracts of all records will be screened by two reviewers independently using the inclusion criteria. For the full-text review, the full text of those articles included after the title and abstract screening will be obtained and uploaded into Covidence. Next, two reviewers will independently screen the full text of all records using the eligibility criteria. Reasons for exclusion of full-text papers that do not meet the inclusion criteria will be recorded and reported in the PRISMA flow diagram. All conflicts at each stage will be resolved by a third reviewer or by the team, where consensus will be obtained by the majority of the team members present.

Data extraction

To pilot the data collection process, all team members will independently extract data from the same five articles selected by the biomedical librarian from the included articles. After extracting the data, the team will meet to assess whether the data items can be extracted correctly, whether any relevant data items are missing, ease of use, and challenges encountered while using the tool and revise the data extraction process, as necessary. If changes are necessary, the data collection form may be revised and re-tested using another set of five randomly selected articles. Any modifications made to the data extraction tool and process will be fully documented in the protocol and eventual manuscript. Once the data collection form is finalized, the authors will proceed to extract the data from all included articles (Table  2 ).

Data from the included articles will be extracted by two reviewers independently using a data extraction tool developed by the review team in Covidence. Any discrepancies or conflicts between the reviewers will be resolved by a third reviewer or by discussion with the team. Data that is missing or unclear will be marked as either not reported or not available.

Data analysis

The data items to collect from each included article are first author’s last name; publication year; study design; study location; total study sample size; sample size for each racial/ethnic group; specific chronic disease studied; PNP symptoms reported; variables and measure/scale used for self-reporting; and general comments. In this review, race will be determined based on origin and/or self-identification, regardless of the person’s geographic location. Categories of race will be based on the National Institutes of Health (NIH) general guidelines on Race and National Origin [ 17 ]. We will not assess the risk of bias of the individual studies included in this review as this step is optional when conducting a scoping review.

Presentation

We will attempt to characterize how and which PNP symptoms are self-reported, for which chronic diseases, and if there are reported differences in self-reporting of the PNP symptoms across racial groups. Tables will be utilized to present the key summary characteristics of the included studies, as well as their major findings that address the research aims. A narrative summary to accompany tables and figures will describe the relation of the results to the scoping review’s research question and aims. Figures may be used to provide a graphical presentation of the different themes formulated based on the analysis.

Protocol and registration

The proposed scoping review will be conducted in accordance with the JBI methodology for scoping reviews [ 18 ] and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [ 19 ]. A protocol was written a priori using the PRISMA Protocol template and was registered on Open Science Framework ( https://osf.io/ps7aw ). The scoping review team will include a biomedical librarian as a methodological expert, a nurse symptom scientist as the content expert, a nurse practitioner, and a doctorally-prepared nurse who will work in tandem with two post-baccalaureate fellows, as reviewers. The team will meet weekly during the screening and data collection steps. Additional experts may be invited during the consultation and dissemination stages of this review.

We hope to identify the relevant and practical implications of the scoping review results as related to clinical decision-making and health outcomes. The authors will present how the results can be utilized in clinical practice, health policy, and research planning. Recommendations on future studies may be formulated, not only based on the results related to the research question but also based on the gaps in present evidence identified during the review.

Availability of data and materials

Data sharing is not applicable to this article as it is a protocol for a scoping review and no datasets were generated or analyzed.

Abbreviations

Joanna Briggs Institute

Medical Subject Headings

Psychoneurophysical

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews

United States of America

World Health Organization

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Acknowledgements

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This scoping review is supported by the Division of Intramural Research, National Institute of Nursing Research and the Office of Research Services, National Institutes of Health Library. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the National Institute of Nursing Research, the Office of Research Services, or the National Institutes of Health Library. The funders did not have any involvement in the conception or writing of the protocol.

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Carielle Joy Rio, Catherine Blumhorst, Catherine A. Kwiat, Christopher M. Nguyen & Leorey N. Saligan

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Conceptualization of review and research question: CJR, AAL, and LNS. Developed search strategy and conducted preliminary searches: AAL. Wrote drafts of protocol manuscript: CJR, AAL. Reviewed the protocol manuscript: CJR, CB, CAK, CMN, AAL, and LNS. Edited the protocol manuscript: CJR and AAL. Approved the final protocol manuscript: CJR, CB, CAK, CMN, AAL, and LNS. Overall supervision for the project: LNS. All authors read and approved the final manuscript.

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Rio, C.J., Blumhorst, C., Kwiat, C.A. et al. Self-reporting of psychoneurophysical (PNP) symptoms in adults with four chronic diseases: a protocol for a scoping review. Syst Rev 13 , 102 (2024). https://doi.org/10.1186/s13643-024-02498-0

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• Chronic disease
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Systematic Reviews

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Older adults’ experiences during the COVID-19 pandemic: a qualitative systematic literature review

• Elfriede Derrer-Merk   ORCID: orcid.org/0000-0001-7241-0808 1 ,
• Maria-Fernanda Reyes-Rodriguez   ORCID: orcid.org/0000-0002-2645-5092 2 ,
• Laura K. Soulsby   ORCID: orcid.org/0000-0001-9071-8654 1 ,
• Louise Roper   ORCID: orcid.org/0000-0002-2918-7628 3 &
• Kate M. Bennett   ORCID: orcid.org/0000-0003-3164-6894 1  

BMC Geriatrics volume  23 , Article number:  580 ( 2023 ) Cite this article

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Relatively little is known about the lived experiences of older adults during the COVID-19 pandemic. We systematically review the international literature to understand the lived experiences of older adult’s experiences during the pandemic.

Design and methodology

This study uses a meta-ethnographical approach to investigate the included studies. The analyses were undertaken with constructivist grounded theory.

Thirty-two studies met the inclusion criteria and only five papers were of low quality. Most, but not all studies, were from the global north. We identified three themes: desired and challenged wellbeing; coping and adaptation; and discrimination and intersectionality.

Overall, the studies’ findings were varied and reflected different times during the pandemic. Studies reported the impact of mass media messaging and its mostly negative impact on older adults. Many studies highlighted the impact of the COVID-19 pandemic on participants' social connectivity and well-being including missing the proximity of loved ones and in consequence experienced an increase in anxiety, feeling of depression, or loneliness. However, many studies reported how participants adapted to the change of lifestyle including new ways of communication, and social distancing. Some studies focused on discrimination and the experiences of sexual and gender minority and ethnic minority participants. Studies found that the pandemic impacted the participants’ well-being including suicidal risk behaviour, friendship loss, and increased mental health issues.

The COVID-19 pandemic disrupted and impacted older adults’ well-being worldwide. Despite the cultural and socio-economic differences many commonalities were found. Studies described the impact of mass media reporting, social connectivity, impact of confinement on well-being, coping, and on discrimination. The authors suggest that these findings need to be acknowledged for future pandemic strategies. Additionally, policy-making processes need to include older adults to address their needs. PROSPERO record [CRD42022331714], (Derrer-Merk et al., Older adults’ lived experiences during the COVID-19 pandemic: a systematic review, 2022).

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Introduction

In March 2020 the World Health Organisation declared a pandemic caused by the virus SARS-CoV2 (COVID-19) [ 1 ]. At this time 118,000 cases in 114 countries were identified and 4,291 people had already lost their lives [ 2 ]. By July 2022, there were over 5.7 million active cases and over 6.4 million deaths [ 2 ]. Despite the effort to combat and eliminate the virus globally, new variants of the virus are still a concern. At the start of the pandemic, little was known about who would be most at risk, but emerging data suggested that both people with underlying health conditions and older people had a higher risk of becoming seriously ill [ 3 ]. Thus, countries worldwide imposed health and safety measures aimed at reducing viral transmission and protecting people at higher risk of contracting the virus [ 4 ]. These measures included: national lockdowns with different lengths and frequencies; targeted shopping times for older people; hygiene procedures (wearing masks, washing hands regularly, disinfecting hands); restricting or prohibiting social gatherings; working from home, school closure, and home-schooling.

Research suggests that lockdowns and protective measures impacted on people’s lives, and had a particular impact on older people. They were at higher risk from COVID-19, with greater disease severity and higher mortality compared to younger people [ 5 ]. Older adults were identified as at higher risk as they are more likely to have pre-existing conditions including heart disease, diabetes, and severe respiratory conditions [ 5 ]. Additionally, recent research highlights that COVID-19 and its safety measures led to increased mental health problems, including increased feelings of depression, anxiety, social isolation, and loneliness, potentially cognitive decline [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 ]. Other studies reported the consequences of only age-based protective health measures including self-isolation for people older people (e.g. feeling old, losing out the time with family) [ 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ].

Over the past decade, the World Health Organisation (WHO) has recognised the importance of risk communication within public health emergency preparedness and response, especially in the context of epidemics and pandemics. Risk communication is defined as “the real-time exchange of information, advice and opinions between experts or officials, and people who face a threat (hazard) to their survival, health or economic or social well-being” ([ 31 ], p5). This includes reporting the risk and health protection measurements through media and governmental bodies. Constructing awareness and building trust in society are essential components of risk communication [ 32 ]. In the context of the pandemic, the WHO noted that individual risk perception helped to prompt problem-solving activities (such as wearing face masks, social distancing, and self-isolation). However, the prolonged perception of pandemic-related uncertainty and risk could also lead to heightened feelings of distress and anxiety [ 31 , 33 ], see also [ 34 , 35 , 36 , 37 ].

This new and unprecedented disease provided the ground for researchers worldwide to investigate the COVID-19 pandemic. To date (August 2022), approximately 8072 studies have been recorded on the U.S. National Library of Medicine ClinicalTrials.gov [ 38 ] and 12002 systematic reviews have been registered at PROSPERO, concerning COVID-19. However, to our knowledge, there is little known about qualitative research as a response to the COVID-19 pandemic and how it impacted older adults’ well-being [ 39 ]. In particular, little is known about how older people experienced the pandemic. Thus, our research question considers: How did older adults experience the COVID-19 pandemic worldwide?

We use a qualitative evidence synthesis (QES) recommended by Cochrane Qualitative and Implementation Methods Group to identify peer-reviewed articles [ 40 ]. This provides an overview of existing research, identifies potential research gaps, and develops new cumulative knowledge concerning the COVID-19 pandemic and older adults’ experiences. QES is a valuable method for its potential to contribute to research and policy [ 41 ]. Flemming and Noyes [ 40 ] argue that the evidence synthesis from qualitative research provides a richer interpretation compared to single primary research. They identified an increasing demand for qualitative evidence synthesis from a wide range of “health and social professionals, policymakers, guideline developers and educationalists” (p.1).

Methodology

A systematic literature review requires a specific approach compared to other reviews. Although there is no consensus on how it is conducted, recent systematic literature reviews have agreed the following reporting criteria are addressed [ 42 , 43 ]: (a) a research question; (b) reporting database, and search strategy; (c) inclusion and exclusion criteria; (d) reporting selection methods; (e) critically appraisal tools; (f) data analysis and synthesis. We applied these criteria in our study and began by registering the research protocol with Prospero [ 44 ].

The study is registered at Prospero [ 44 ]. This systematic literature review incorporates qualitative studies concerning older adults’ experiences during the COVID-19 pandemic.

Search strategy

The primary qualitative articles were identified via a systematic search as per the qualitative-specific SPIDER approach [ 45 ]. The SPIDER tool is designed to structure qualitative research questions, focusing less on interventions and more on study design, and ‘samples’ rather than populations, encompassing:

S-Sample. This includes all articles concerning older adults aged 60 +  [ 1 ].

P-Phenomena of Interest. How did older adults experience the COVID-19 pandemic?

D-Design. We aim to investigate qualitative studies concerning the experiences of older adults during the COVID-19 pandemic.

E-Evaluation. The evaluation of studies will be evaluated with the amended Critical Appraisal Skills Programme CASP [ 46 ].

R-Research type Qualitative

Information source

The following databases were searched: PsychInfo, Medline, CINAHL, Web of Science, Annual Review, Annual Review of Gerontology, and Geriatrics. A hand search was conducted on Google Scholar and additional searches examined the reference lists of the included papers. The keyword search included the following terms: (older adults or elderly) AND (COVID-19 or SARS or pandemic) AND (experiences); (older adults) AND (experience) AND (covid-19) OR (coronavirus); (older adults) AND (experience) AND (covid-19 OR coronavirus) AND (Qualitative). Additional hand search terms included e.g. senior, senior citizen, or old age.

Inclusion and exclusion criteria

Articles were included when they met the following criteria: primary research using qualitative methods related to the lived experience of older adults aged 60 + (i.e. the experiences of individuals during the COVID-19 pandemic); peer-reviewed journal articles published in English; related to the COVID-19 pandemic; empirical research; published from 2020 till August 2022.

Articles were excluded when: papers discussed health professionals’ experiences; diagnostics; medical studies; interventions; day-care; home care; or carers; experiences with dementia; studies including hospitals; quantitative studies; mixed-method studies; single-case studies; people under the age of 60; grey literature; scoping reviews, and systematic reviews. We excluded clinical/care-related studies as we wanted to explore the everyday experiences of people aged 60 + . Mixed-method studies were excluded as we were interested in what was represented in solely qualitative studies. However, we acknowledge, that mixed-method studies are valuable for future systematic reviews.

Meta-ethnography

The qualitative synthesis was undertaken by using meta-ethnography. The authors have chosen meta-ethnography over other methodologies as it is an inductive and interpretive synthesis analysis and is uniquely “suited to developing new conceptual models and theories” ([ 47 ], p 2), see also [ 48 ]. Therefore, it combines well with constructivist grounded theory methodology. Meta-ethnography also examines and identifies areas of disagreements between studies [ 48 ].

This is of particular interest as the lived experiences of older adults during the COVID-19 pandemic were likely to be diverse. The method enables the researcher to synthesise the findings (e.g. themes, concepts) from primary studies, acknowledging primary data (quotes) by “using a unique translation synthesis method to transcend the findings of individual study accounts and create higher order” constructs ([ 47 ], p. 2). The following seven steps were applied:

Getting started (identify area of interest). We were interested in the lived experiences of older adults worldwide.

Deciding what was relevant to the initial interest (defining the focus, locating relevant studies, decision to include studies, quality appraisal). We decided on the inclusion and exclusion criteria and an appropriate quality appraisal.

Reading the studies. We used the screening process described below (title, abstract, full text)

Determining how the studies were related (extracting first-order constructs- participants’ quotes and second-order construct- primary author interpretation, clustering the themes from the studies into new categories (Table 3 ).

Translating the studies into one another (comparing and contrasting the studies, checking commonalities or differences of each article) to organise and develop higher-order constructs by using constant comparison (Table 3 ). Translating is the process of finding commonalities between studies [ 48 ].

Synthesising the translation (reciprocal and refutational synthesis, a lines of argument synthesis (interpretation of the relationship between the themes- leads to key themes and constructs of higher order; creating new meaning, Tables 2 , 3 ),

Expressing the synthesis (writing up the findings) [ 47 , 48 ].

Screening and Study Selection

A 4-stage screening protocol was followed (Fig.  1 Prisma). First, all selected studies were screened for duplicates, which were deleted. Second, all remaining studies were screened for eligibility, and non-relevant studies were excluded at the preliminary stage. These screening steps were as follows: 1. title screening; 2. abstract screening, by the first and senior authors independently; and 3. full-text screening which was undertaken for almost all papers by the first author. However, 2 papers [ 9 , 23 ] were assessed independently by LS, LR, and LMM to avoid a conflict of interest. The other co-authors also screened independently a portion of the papers each, to ensure that each paper had two independent screens to determine inclusion in the review [ 49 ]. This avoided bias and confirmed the eligibility of the included papers (Fig.  1 ). Endnote reference management was used to store the articles and aid the screening process.

Prisma flow diagram adapted from Page et al. [ 50 ]. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ, 372, n71. https://doi.org/10.1136/bmj.n71 )

Data extraction

After title and abstract screening, 39 papers were selected for reading the full article. 7 papers were excluded after the full-text assessment (1 study was conducted in 2017, but published in 2021; 2 papers were not fully available in English, 2 papers did not address the research question, 1 article was based on a conference abstract only, 1 article had only one participant age 65 +).

The full-text screening included 32 studies. All the included studies, alongside the CASP template, data extraction table, the draft of this article, and translation for synthesising the findings [ 47 , 48 ] were available and accessible on google drive for all co-authors. All authors discussed the findings in regular meetings.

Quality appraisal

A critical appraisal tool assesses a study for its trustworthiness, methodological rigor, and biases and ensures “transparency in the assessment of primary research” ([ 51 ], p. 5); see also [ 48 , 49 , 50 , 51 , 52 , 53 ]. There is currently no gold standard for assessing primary qualitative studies, but different authors agreed that the amended CASPS checklist was appropriate to assess qualitative studies [ 46 , 54 ]. Thus, we use the amended CASP appraisal tool [ 42 ]. The amended CASP appraisal tool aims to improve qualitative evidence synthesis by assessing ontology and epistemology (Table 1 CASP appraisal tool).

A numerical score was assigned to each question to indicate whether the criteria had been met (= 2), partially met (= 1), or not met (= 0) [ 54 ]; see also [ 55 ]. The score 16 – 22 are considered to be moderate and high-quality studies. The studies scored 15 and below were identified as low-quality papers. Although we focus on higher-quality papers, we did not exclude papers to avoid the exclusion of insightful and meaningful data [ 42 , 48 , 52 , 53 , 54 , 55 , 56 , 57 ]. The quality of the paper was considered in developing the evidence synthesis.

We followed the appraisal questions applied for each included study and answered the criteria either ‘Yes’, ‘Cannot tell’, or ‘No’. (Table 1 CASP appraisal criteria). The tenth question asking the value of the article was answered with ‘high’ of importance, ‘middle’, or low of importance. The new eleventh question in the CASP tool concerning ontology and epistemology was answered with yes, no, or partly (Table 1 ).

Data synthesis

The data synthesis followed the seven steps of Meta-Ethnography developed by Noblit & Hare [ 58 ], starting the data synthesis at step 3, described in detail by [ 47 ]. This encompasses: reading the studies; determining how the studies are related; translating the studies into one another; synthesis the translations; and expressing synthesis. This review provides a synthesis of the findings from studies related to the experiences of older adults during the COVID-19 pandemic. The qualitative analyses are based on constructivist grounded theory [ 59 ] to identify the experiences of older adults during the COVID-19 pandemic (non-clinical) populations. The analysis is inductive and iterative, uses constant comparison, and aims to develop a theory. The qualitative synthesis encompasses all text labelled as ‘results’ or ‘findings’ and uses this as raw data. The raw data includes participant’s quotes; thus, the synthesis is grounded in the participant's experience [ 47 , 48 , 60 , 61 ]. The initial coding was undertaken for each eligible article line by line. Please see Table 2 Themes per author and country. Focused coding was applied using constant comparison, which is a widely used approach in grounded theory [ 61 ]. In particular, common and recurring as well as contradicting concepts within the studies were identified, clustered into categories, and overarching higher order constructs were developed [ 47 , 48 , 60 ] (Tables 2 , 3 , 4 ).

We identified twenty-seven out of thirty-two studies as moderate-high quality; they met most of the criteria (scoring 16/22 or above on the CASP; [ 54 ]. Only five papers were identified as low qualitative papers scoring 15 and below [ 71 , 73 , 74 , 86 , 91 ]. Please see the scores provided for each paper in Table 4 . The low-quality papers did not provide sufficient details regarding the researcher’s relationship with the participants, sampling and recruitment, data collection, rigor in the analysis, or epistemological or ontological reasoning. For example, Yildirim [ 91 ] used verbatim notes as data without recording or transcribing them. This article described the analytical process briefly but was missing a discussion of the applied reflexivity of using verbatim notes and its limitations [ 92 ].

This systematic review found that many studies did not mention the relationship between the authors and the participant. The CASP critical appraisal tool asks: Has the relationship between the researcher and participants been adequately considered? (reflecting on own role, potential bias). Many studies reported that the recruitment was drawn from larger studies and that the qualitative study was a sub-study. Others reported that participants contacted the researcher after advertising the study. One study Goins et al., [ 72 ] reported that students recruited family members, but did not discuss how this potential bias impacted the results.

Our review brings new insights into older adults’ experiences during the pandemic worldwide. The studies were conducted on almost all continents. The majority of the articles were written in Europe followed by North America and Canada (4: USA; 3: Canada, UK; 2: Brazil, India, Netherlands, Sweden, Turkey 2; 1: Austria, China, Finland, India/Iran, Mauritius, New Zealand, Serbia, Spain, Switzerland, Uganda, UK/Ireland, UK/Colombia) (see Fig.  2 ). Note, as the review focuses on English language publications, we are unable to comment on qualitative research conducted in other languages see [ 72 ].

Numbers of publications by country

The characteristics of the included studies and the presence of analytical themes can be found in Table 4 . We used the following characteristics: Author and year of publication, research aims, the country conducted, Participant’s age, number of participants, analytical methodology, CASP score, and themes.

We identified three themes: desired and challenged wellbeing; coping and adaptation; discrimination and intersectionality. We will discuss the themes in turn.

Desired and challenged wellbeing

Most of the studies reported the impact of the COVID-19 pandemic on the well-being of older adults. Factors which influenced wellbeing included: risk communication and risk perception; social connectivity; confinement (at home); and means of coping and adapting. In this context, well-being refers to the evidence reported about participants' physical and mental health, and social connectivity.

Risk perception and risk communication

Politicians and media transmitted messages about the response to the pandemic to the public worldwide. These included mortality and morbidity reports, and details of health and safety regulations like social distancing, shielding- self-isolation, or wearing masks [ 34 , 35 , 36 , 37 ]. As this risk communication is crucial to combat the spread of the virus, it is also important to understand how people perceived the reporting during the pandemic.

Seven studies reported on how the mass media impacted participants' well-being [ 23 , 67 , 68 , 70 , 72 , 81 , 85 ]. Sangrar et al. [ 68 ] investigated how older adults responded to COVID-19 messaging: “My reaction was to try to make sure that I listen to everything and [I] made sure I was aware of all the suggestions and the precautions that were being expressed by various agencies …”. (p. 4). Other studies reported the negative impact on participants' well-being of constant messaging and as a consequence stopped watching the news to maintain emotional well-being [ 3 , 67 , 68 , 70 , 72 , 81 , 85 ]. Derrer-Merk et al. [ 23 ] reported one participant said that “At first, watching the news every day is depressing and getting more and more depressing by the day, so I’ve had to stop watching it for my own peace of mind” (p. 13). In addition, news reporting impacted participants’ risk perception. For example, “Sometimes we are scared to hear the huge coverage of COVID-19 news, in particular the repeated message ‘older is risky’, although the message is useful.” ([ 81 ], p5).

• Social connectivity

Social connectivity and support from family and community were found in fourteen of the studies as important themes [ 9 , 62 , 66 , 67 , 68 , 75 , 76 , 77 , 78 , 79 , 80 , 83 , 84 , 90 ].

The impact of COVID-19 on social networks highlighted the diverse experiences of participants. Some participants reported that the size of social contact was reduced: “We have been quite isolated during this corona time” ?([ 80 ], p. 3). Whilst other participants reported that the network was stable except that the method of contact was different: “These friends and relatives, they visited and called as often as before, but of course, we needed to use the telephone when it was not possible to meet” ([ 77 ], p. 5). Many participants in this study did not want to expand their social network see also [ 9 , 77 , 78 , 79 ]. Hafford-Letchfield et al. [ 76 ] reported that established social networks and relationships were beneficial for the participants: “Covid has affected our relationship (with partner), we spend some really positive close time together and support each other a lot” (p. 7).

On the other hand, other studies reported decreases of, and gaps in, social connectedness: “I couldn’t do a lot of things that I’ve been doing for years. That was playing competitive badminton three times a week, I couldn’t do that. I couldn’t get up early and go volunteer in Seattle” [ 9 , 67 , 75 ]. A loss of social connection with children and grandchildren was often mentioned: “We cannot see our grandchildren up close and personal because, well because they [the parents] don’t want us, they don’t want to risk our being with the kids … it’s been an emotional loss exacerbated by the COVID thing” ([ 68 ] p.10); see also [ 9 , 67 , 78 ]. On the contrary, Chemen & Gopalla [ 66 ] note that those older adults who were living with other family members reported that they were more valued: “Last night my daughter-in-law thanked me for helping with my granddaughter” (p.4).

Despite reports of social disconnectedness, some studies highlighted the importance of support from family members and how support changed during the COVID-19 pandemic [ 9 , 62 , 81 , 83 , 90 ]. Yang et al. [ 90 ] argued that social support was essential during the Lockdown in China: “N6 said: ‘I asked my son-in-law to take me to the hospital” (p. 4810). Mahapatra et al. [ 81 ] found, in an Indian study, that the complex interplay of support on different levels (individual, family, and community) helped participants to adapt to the new situation. For example, this participant reported that: “The local police are very helpful. When I rang them for something and asked them to find out about it, they responded immediately” (p. 5).

Impact of confinement on well being

Most articles highlighted the impact of confinement on older adults’ well-being [ 9 , 62 , 63 , 65 , 67 , 69 , 70 , 72 , 75 , 77 , 78 , 79 , 81 , 82 , 83 , 85 , 89 , 90 ].

Some studies found that participants maintained emotional well-being during the pandemic and it did not change their lifestyle [ 79 , 80 , 82 , 83 , 89 , 92 ]: “Actually, I used this crisis period to clean my house. Bookcases are completely cleaned and I discarded old books. Well, we have actually been very busy with those kind of jobs. So, we were not bored at all” ([ 79 ], p. 5). In McKinlay et al. [ 82 ]’s study, nearly half of the participants found that having a sense of purpose helped to maintain their well-being: “You have to have a purpose you see. I think mental resilience is all about having a sense of purpose” (p. 6).

However, at the same time, the majority of the articles (12 out of 18) highlighted the negative impact of confinement and social distancing. Participants talked of increased depressive feelings and anxiety. For example, one of Akkus et al.’s [ 62 ] participants said: “... I am depressed; people died. Terrible disease does not give up, it always kills, I am afraid of it …” (p. 549). Similarly, one of Falvo et al.’s [ 67 ] participants remarked: “I am locked inside my house and I am afraid to go out” (p. 7).

Many of the studies reported the negative impact of loneliness as a result of confinement on participants’ well-being including [ 69 , 70 , 72 , 78 , 79 , 90 , 93 ]. Falvo et al. [ 67 ] reported that many participants experienced loneliness: “What sense does it make when you are not even able to see a family member? I mean, it is the saddest thing not to have the comfort of having your family next to you, to be really alone” (p. 8).

Not all studies found a negative impact on loneliness. For example, a “loner advantage” was found by Xie et al. ([ 82 ], p. 386). In this study participants found benefits in already being alone “It’s just a part of who I am, and I think that helps—if you can be alone, it really is an asset when you have to be alone” ([ 82 ], p. 386).

Bundy et al. [ 80 ] investigated loneliness from already lonely older adults and found that many participants did not attribute the loneliness to the pandemic: “It’s not been a whole lot, because I was already sitting around the house a whole lot anyway ( …). It’s basically the same, pretty well … I’d pretty well be like this anyway with COVID or without COVID” (p. 873) (see also [ 83 ]).

A study from Serbia investigated how the curfew was perceived 15 months afterward. Some participants were calm: “I realized that … well … it was simply necessary. For that reason, we accepted it as a measure that is for the common good” ([ 70 ], p.634). Others were shocked: “Above all, it was a huge surprise and sort of a shock, a complete shock because I have never, ever seen it in my life and I felt horrible, because I thought that something even worse is coming, that I even could not fathom” ([ 70 ], p. 634).

The lockdowns brought not only mental health issues to the fore but impacted the physical health of participants. Some reported they were fearful of the COVID-19 pandemic: “... For a little while I was afraid to leave, to go outside. I didn’t know if you got it from the air” ([ 75 ]. p. 6). Another study reported: “It’s been important for me to walk heartily so that I get a bit sweaty and that I breathe properly so that I fill my lungs—so that I can be prepared—and be as strong as possible, in case I should catch that coronavirus” ([ 77 ], p. 9); see also [ 70 , 78 , 82 , 85 ].

Coping and adaptation

Many studies mentioned older adults’ processes of coping and adaptation during the pandemic [ 63 , 64 , 68 , 69 , 72 , 75 , 79 , 81 , 85 , 87 , 88 , 89 , 90 ].

A variety of coping processes were reported including: acceptance; behavioural adaptation; emotional regulation; creating new routines; or using new technology. Kremers et al. [ 79 ] reported: “We are very realistic about the situation and we all have to go through it. Better days will come” (p. e71). Behavioural adaptation was reported: “Because I’m asthmatic, I was wearing the disposable masks, I really had trouble breathing. But I was determined to find a mask I could wear” ([ 68 ], p. 14). New routines with protective hygiene helped some participants at the beginning of the pandemic to cope with the health threat: “I am washing my hands all the time, my hands are raw from washing them all the time, I don't think I need to wash them as much as I do but I do it just in case, I don’t have anybody coming in, so there is nobody contaminating me, but I keep washing” ([ 69 ], p. 4391); see also [ 72 ]. Verhage et al. [ 87 ] reported strategies of coping including self-enhancing comparisons, distraction, and temporary acceptance: “There are so many people in worse circumstances …” (p. e294). Other studies reported how participants used a new technology: “I have recently learned to use WhatsApp, where I can make video phone calls.” ([ 88 ], p. 163); see also [ 89 ].

Discrimination -intersectionality (age and race/gender identity)

Seven studies reported ageism, racism, and gender discrimination experienced by older adults during the pandemic [ 23 , 63 , 67 , 70 , 76 , 84 , 88 ].

Prigent et al. [ 84 ], conducted in a New Zealand study, found that ageism was reciprocal. Younger people spoke against older adults: “why don’t you do everyone a favour and drop dead you f******g b**** it’s all because of ones like you that people are losing jobs” (p. 11). On the other hand, older adults spoke against the younger generation: “Shame to see the much younger generations often flout the rules and generally risk the gains made by the team. Sheer arrogance on their part and no sanctions applied” (p.11). Although one study reported benevolent ageism [ 23 ] most studies found hostile ageism [ 23 , 63 , 67 , 70 , 76 , 84 ]. One study from Canada exploring 15 older adult’s Chinese immigrants’ experiences reported racism as people around them thought they would bring the virus into the country. The negative impact on existing friendships was told by a Chinese man aged 69 “I can tell some people are blatantly despising us. I can feel it. When I talked with my Caucasian friends verbally, they would indirectly blame us for the problem. Eventually, many of our friendships ended because of this issue” ([ 88 ], p161). In addition, this study reported ageism when participants in nursing homes felt neglected by the Canadian government.

Two papers reported experiences of sexual and gender minorities (SGM) (e.g. transgender, queer, lesbian or gay) and found additional burdens during the pandemic [ 63 , 76 ]. People experienced marginalisation, stereotypes, and discrimination, as well as financial crisis: “I have faced this throughout life. Now people look at me in a way as if I am responsible for the virus.” ([ 63 ], p. 6). The consequence of marginalisation and ignorance of people with different gender identities was also noted by Hafford- Letchfield et al. [ 76 ]: “People have been moved out of their accommodation into hotels with people they don't know …. a gay man committed suicide, community members know of several that have attempted suicide. They are feeling pretty marginalised and vulnerable and you see what people are writing on the chat pages” (p.4). The intersection of ageism, racism, and heterosexism and its negative impact on people’s well-being during the pandemic reflects additional burden and stressors for older adults.

This systematic literature review is important as it provides new insights into the lived experiences of older adults during the COVID-19 pandemic, worldwide. Our study highlights that the COVID-19 pandemic brought an increase in English-written qualitative articles to the fore. We found that 32 articles met the inclusion criteria but 5 were low quality. A lack of transparency reduces the trustworthiness of the study for the reader and the scientific community. This is particularly relevant as qualitative research is often criticised for its bias or lack of rigor [ 94 ]. However, their findings are additional evidence for our study.

Our aim was to explore, in a systematic literature review, the lived experiences of older adults during the COVID-19 pandemic worldwide. The evidence highlights the themes of desired and challenged wellbeing, coping and adaptation, and discrimination and intersectionality, on wellbeing.

Perceived risk communication was experienced by many participants as overwhelming and anxiety-provoking. This finding supports Anwar et al.’s [ 37 ] study from the beginning of the pandemic which found, in addition to circulating information, that mass media influenced the public's behaviour and in consequence the spread of disease. The impact can be positive but has also been revealed to be negative as well. They suggest evaluating the role of the mass media in relation to what and how it has been conveyed and perceived. The disrupted social connectivity found in our review supports earlier studies that reported the negative impact of people’s well-being [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ] at the beginning of the pandemic. This finding is important for future health crisis management, as the protective health measures such as confinement or self-isolation had a negative impact on many of the participants’ emotional wellbeing including increased anxiety, feelings of depression, and loneliness during the lockdowns. As a result of our review, future protective health measures should support people’s desire to maintain proximity with their loved ones and friends. However, we want to stress that our findings are mixed.

The ability of older adults to adapt and cope with the health crisis is important: many of the reported studies noted the diverse strategies used by older people to adapt to new circumstances. These included learning new technologies or changing daily routines. Politicians and the media and politicians should recognise both older adults' risk of disease and its consequences, but also their adaptability in the face of fast-changing health measures. This analysis supports studies conducted over the past decades on lifespan development, which found that people learn and adapt livelong to changing circumstances [ 95 , 96 , 97 ].

We found that discrimination against age, race, and gender identity was reported in some studies, in particular exploring participants’ experiences with immigration backgrounds and sexual and gender minorities. These studies highlighted the intersection of age and gender or race and were additional stressors for older adults and support the findings from Ramirez et al. [ 98 ] This review suggests that more research should be conducted to investigate the experiences of minority groups to develop relevant policies for future health crises.

Our review was undertaken two years after the pandemic started. At the cut-off point of our search strategy, no longitudinal studies had been found. However, in December 2022 a longitudinal study conducted in the USA explored older adult’s advice given to others [ 99 ]. They found that fostering and maintaining well-being, having a positive life perspective, and being connected to others were coping strategies during the pandemic [ 100 ]. This study supports the results of the higher order constructs of coping and adaptation in this study. Thus, more longitudinal studies are needed to enhance our understanding of the long-term consequences of the COVID-19 pandemic. The impact of the COVID-19 restrictions on older adults’ lives is evident. We suggest that future strategies and policies, which aim to protect older adults, should not only focus on the physical health threat but also acknowledge older adults' needs including psychological support, social connectedness, and instrumental support. The policies regarding older adult’s protections changed quickly but little is known about older adults’ involvement in decision making [ 100 ]. We suggest including older adults as consultants in policymaking decisions to ensure that their own self-determinism and independence are taken into consideration.

There are some limitations to this study. It did not include the lived experiences of older adults in care facilities or hospitals. The studies were undertaken during the COVID-19 pandemic and therefore data collection was not generally undertaken face-to-face. Thus, many studies included participants who had access to a phone, internet, or email, others could not be contacted. Additionally, we did not include published papers after August 2022. Even after capturing the most commonly used terms and performing additional hand searches, the search terms used might not be comprehensive. The authors found the quality of the papers to be variable, and their credibility was in question. We acknowledge that more qualitative studies might have been published in other languages than English and were not considered in this analysis.

To conclude, this systematic literature review found many similarities in the experiences of older adults during the Covid-19 pandemic despite cultural and socio-economic differences. However, we stress to acknowledge the heterogeneity of the experiences. This study highlights that the interplay of mass media reports of the COVID-19 pandemic and the policies to protect older adults had a direct impact on older adults’ well-being. The intersection of ‘isms’ (ageism, racism, and heterosexism) brought an additional burden for some older adults [ 98 ]. These results and knowledge about the drawbacks of health-protecting measures need to be included in future policies to maintain older adults’ well-being during a health crisis.

Availability of data and materials

The systematic literature review is based on already published articles. And all data analysed during this study are included in this manuscript. No additional data was used.

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Elfriede Derrer-Merk contributed to the design, analysis, and writing the draft. Maria-Fernanda Rodriguez-Reyes contributed to the analysis, revised the draft, and approved the submission. Laura K. Soulsby contributed to the analysis, revised the draft, and approved the submission. Louise Roper contributed to the analysis, revised the draft, and approved the submission. Kate M. Bennett contributed to the design, analysis, writing the draft, and approved the submission.

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Derrer-Merk, E., Reyes-Rodriguez, MF., Soulsby, L.K. et al. Older adults’ experiences during the COVID-19 pandemic: a qualitative systematic literature review. BMC Geriatr 23 , 580 (2023). https://doi.org/10.1186/s12877-023-04282-6

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DOI : https://doi.org/10.1186/s12877-023-04282-6

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